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Impact of Dental Care on Health Care Events and Costs New York State Medicaid, Adults 40-64 years
Kevin Malloy MPH, New York State Department of Health Ira Lamster DDS, MMSc, Stony Brook University
Preliminary Findings
2
Background
3
Origin of Current Study
• Oral infections and the resulting inflammatory response are risk factors in the progression of some Non-Communicable Diseases (NCDs)
• Recent studies have shown reduced heath care costs and improved outcomes among those who received preventive oral care and with treatment of periodontal disease
• To-date, research has primarily looked at private payer populations
4
Study Objectives
• To investigate the relationship between utilization of dental care, health care events, and costs in a high need public payer population (NYS Medicaid)
• Describe these relationships for NCDs linked to dental health
5
• As of November 2018, New York Medicaid enrollment was more than 6.5 million individuals
• Majority (nearly 80%) enrolled in managed care
– Includes individuals with specialized health care needs including managed long term care, HIV care, mental health and substance use services, and care for developmental disabilities
• Combined federal/state/local spending in 2019 = $70.2 Billion1
– ~32% of state budget
Medicaid in New York State
1. https://www.budget.ny.gov/pubs/archive/fy19/exec/fy19book/HealthCare.pdf
6
NYS Medicaid Dental Benefit Package • Covers “Essential Services”
– Preventive, prophylactic, and other routine dental care – Services and supplies required to alleviate a serious health
condition – Inpatient diagnostic, palliative, and therapeutic dental care
7
NYS Medicaid Dental Benefit Exclusions Non covered services include: • Periodontal surgery and crown lengthening • Molar root canal for members 21 years and over* • Immediate full or partial dentures • Fixed partial dentures* • Replacement of partial or full dentures prior to schedule* • Cosmetic dentistry • Adult orthodontics • Implants (unless medically necessary)
*May be covered under certain circumstances including medical necessity
8
Prophylaxis Allowances and Policy
• Prophylaxis: Once per six-month period
• Periodontal Maintenance: Once per six-month period
Note: Not to be used in conjunction (within six-months of each other), or on the same date of service as periodontal root planning and scaling
9
Treatment Allowances and Policy
• Endodontics ‒ Prior authorization required
• Surgical (Gingivectomy or gingivoplasty)
‒ Reimbursable solely for the correction of severe hyperplasia or hypertrophy associated with drug therapy, hormonal disturbances, or congenital defects
10
Treatment Allowances and Policy • Non-Surgical (Root Planning and Scaling)
‒ Must demonstrate clinical loss of periodontal attachment, and; • Periodontal pockets and sub-gingival accretions on cemental surfaces in the
quadrant(s) being treated, and/or;
• Radiographic evidence of crestal bone loss and changes in crestal lamina dura, and/or radiographic evidence of root surface calculus.
‒ Limit: every two years (per quad). No more than two quads on single date.
• Extractions ‒ Prior authorization for certain procedures
11
Study Methodology
12
Specifications
• Study period: Three years, July 1, 2012 – June 30, 2015 ‒ Dental care became part of the managed care plan benefit package in 2012
• Population: ‒ Adults ages 40 – 64 ‒ Not eligible for Medicare (dually eligible) ‒ Continuously enrolled in NYS Medicaid for 36 month study period ‒ Exclusions: residents of long term care facilities and those receiving
hospice services
13
Outcomes and Comparisons • Outcomes of Interest
– Events • Emergency Department (ED)
Visits • Hospitalizations
– Costs • ED • Hospitalization • Pharmacotherapy • Total Cost of Health Care,
Excluding Dental
• Comparison Groups – No Dental Care (referent)
– Any Preventive Care* – Preventive Care w/o Anti-Infective Tx** – Preventive Care with Anti-Infective Tx – Anti-Infective Tx w/o Preventive Care
* Any preventive care group is not mutually exclusive from the other preventive care groups ** Anti-Infective Therapy (Tx) was defined as tooth extraction and/or endodontic therapy
14
Non-Communicable Disease (NCD) Cohorts • Cardiovascular Disease (CVD)
– Major cardiac septal anomalies – Major congenital heart diagnosis – CHF – Valvular disorders – Anginas and Ischemic heart disease – Myocardial infarction – Arterial fibrillation – Dysrhythmias and conduction disorders – Hx coronary artery bypass – Hx coronary angioplasty – Cardiac device status – Coronary atherosclerosis – Hypertension – Ventricular and atrial septal defects – Minor chronic diagnosis – Other major cardiovascular diagnoses
• Diabetes Mellitus
• Respiratory Disease – Major anomalies – COPD and bronchiectasis – Chronic pulmonary diagnoses – Asthma – Chronic bronchitis
• Cognitive Impairment – Neurodegenerative diagnosis except multiple
sclerosis and Parkinson’s – Alzheimer’s Disease and other dementias
Identified using 3M® Clinical Risk Grouping Software
15
Analysis
• Demographics
• Cross-sectional (yearly)
• Longitudinal: Utilization in years 1 and 2 with outcomes in year 3
• Effect of increasing frequency of preventive care utilization
• Effects within NCD cohorts
16
Preliminary Findings
17
Cohort Demographics
19.2%
24.3% 24.0% 21.5%
11.0%
40-44 45-49 50-54 55-59 60-64
Years
Age
58.2
41.8
Sex
Female Male
Final Cohort Size: n= 535,038 25.3%
18.2% 16.9%
21.8%
4.8%
13.1% Race
White Black Asian
Hispanic Others Unknown
18
94.1
5.9
Medicaid Program
Managed care Fee for service
Cohort Demographics
3.7% 9.2%
5.5% 5.7% 6.8%
68.8%
0%
10%
20%
30%
40%
50%
60%
70%
Northeast Western Central Hudson Valley
Long Island New York City
Region of Residence in NYS
19
Cohort Demographics Clinical Risk Group Assignment* % of Cohort
Healthy 17.1 %
Significant Acute Disease 3.0 %
Single Minor Chronic Disease 6.5 %
Minor Chronic Disease in Multiple Organ Systems 3.3 %
Single Dominant Disease or Moderate Chronic 20.5 %
Chronic Disease in Multiple Organ Systems 40.4 %
Dominant Chronic Disease in 3 + Organ Systems 4.0 %
Dominant Metastatic Malignancies 0.7 %
Catastrophic Conditions 4.7 %
*Assignment generated using 3M® Clinical Risk Grouping Software
20
Cohort Demographics
• More than a quarter (27%) received Supplemental Security Income (SSI) from the Federal Government based on being aged, blind, or disabled
• More than a third (36%) received cash assistance from the State
21
27.72%
15.69%
8.87%
2.80%
2.21%
1.43%
0.02%
0% 5% 10% 15% 20% 25% 30%
Preventive Care Restoration
Extraction Emergency Dental
Root Planing and Scaling Endodontic
Periodontal Surgery
Percent of Cohort Receiving at Least One Service
Percent of Study Cohort Utilizing Dental Services*, 2012-2013
* Not mutually exclusive
Utilization of Dental Services
22
Comparison Groups
60%
28% 21%
7% 5%
0%
10%
20%
30%
40%
50%
60%
70%
No Dental Any PC* PC without AI PC with AI AI without PC
Percent of Cohort by Utilization Category, 2012-2013
* Not mutually exclusive from other groups with PC Note: Mutually exclusive groups do not sum to 100 because of utilization of other dental services
Key: PC = Preventive Care AI = Anti-Infective Therapy
23
Cross-sectional: Event Rates by Dental Care Utilization, July 2012 – June 2013
Key: PC = Preventive Care AI = Anti-Infective Therapy
19.6
15.2 14.2
18.5
26.7
No Dental Any PC** PC without AI
PC with AI AI without PC
Hospitalization Rate Per 100 People
74.6 65.1 61.2
77.2
114.7
No Dental Any PC** PC without AI
PC with AI AI without PC
ED Visit Rate Per 100 People
* *
*
Statistically different from No Dental (p < 0.01) *
* *
*
* *
Referent Group
** Not mutually exclusive from other groups with PC
24
Cross-sectional: Costs1 by Dental Care Utilization, July 2012 – June 2013
Key: PC = Preventive Care AI = Anti-Infective Therapy ED = Emergency Department Visit Hosp =Hospitalization Rx = Prescription Drug
1. Per Person Average Cost. Total healthcare cost excludes cost of dental care
$4,961 $4,220 $4,025
$4,825
$6,443
No Dental Any PC** PC without AI
PC with AI AI without PC
ED/HOSP/RX
$8,687 $9,512 $9,250
$10,321 $11,447
No Dental Any PC** PC without AI
PC with AI AI without PC
Total Healthcare
* *
*
*
Statistically different from No Dental (p < 0.01) *
* * *
Referent Group
** Not mutually exclusive from other groups with PC
25
Longitudinal: Year 3 Event Rates by Dental Utilization in Years 1 and 2
76.4 68.5 62.8
79.0
116.3
No Dental Any PC** PC without AI
PC with AI AI without PC
ED Visit Rate Per 100 People
* *
*
*
Key: PC = Preventive Care AI = Anti-Infection Therapy
21.1
16.2 14.4
19.6
30.0
No Dental Any PC** PC without AI
PC with AI AI without PC
Hospitalization Rate Per 100 People
Statistically different from No Dental (p < 0.01) *
* *
*
*
Referent Group
** Not mutually exclusive from other groups with PC
26
Longitudinal: Year 3 Costs1 by Dental Utilization in Years 1 and 2
Key: PC = Preventive Care AI = Anti-Infective Therapy ED = Emergency Department Visit Hosp =Hospitalization Rx = Prescription Drug
1. Per Person Average Cost. Total health care cost excludes cost of dental care
$6,524 $5,705 $5,209
$6,621
$8,660
No Dental Any PC** PC without AI
PC with AI AI without PC
ED/HOSP/RX
$11,227 $11,271 $10,500
$12,692 $14,348
No Dental Any PC** PC without AI
PC with AI AI without PC
Total Healthcare
Statistically different from No Dental (p < 0.01) *
* *
* *
* *
Referent Group
** Not mutually exclusive from other groups with PC
27
Impact of Frequency of Preventive Care
Key: ED = Emergency Department Visit Hosp =Hospitalization Rx = Prescription Drug Note: Overall change in rates across increasing frequency of preventive care was statistically significant (p<0.001) for all categories of care
85.3 75.4
64.4 57.1 55.1
23.2 18.8 14.2 12.6 11.9
0
20
40
60
80
100
None One Two Three Four or More
Year 3 Events Rates Per 100 People, by Number of Preventive Visits over Years 1 and 2
ED Hospitalizations
28
NCDs Focus: Difference in Preventive Care vs No Dental Rate reductions and cost savings among those with NCDs
Year 3 outcomes based on utilization of services in years 1 and 2
•ED (-13.1 per 100 ppl) •Hosp (-7.6 per 100 ppl) •Total Cost PP (-$772)
CVD
•ED (-16.9 per 100 ppl) •Hosp (-10.3 per 100 ppl) •Total Cost PP (-$2,065)
Diabetes
•ED (-25.5 per 100 ppl) •Hosp (-13.1 per 100 ppl) •Total Cost PP (-$2,259)
Respiratory
•ED (-66.6 per 100 ppl) •Hosp (-30.9 per 100 ppl) •Total Cost PP (-$8,194)
Cognitive Impairment
Key: ED = Emergency Department Visit Hosp =Hospitalization Total Cost PP = Total average cost per person, excluding cost of any dental care
29
Concluding Remarks • This study is comprehensively examining the effect of dental treatment on
health care outcomes and costs in a Medicaid program • Preliminary findings
– Provision of preventive dental services is associated with: • Reduced ED and hospitalization rates • Reduced ED, Hospitalization, and Rx costs • Reduced Total Healthcare Costs for those with NCDs
– Beneficial effects are modified by: • The need for anti-infective therapy (endodontic treatment and or tooth extraction) • Frequency of preventive care utilized
• This analysis is continuing, to more specifically define associations and adjust
for the unique needs of subsets of this Medicaid population
30
Acknowledgements
Analytic Support Provided by: Yizhao Xi, Data Analyst, New York State Department of Health
Bin Cheng PhD, Associate Professor of Biostatistics, Columbia University Medical Center
This study is supported by: The New York State Department of Health;
The John A. Hartford Foundation; The DentaQuest Foundation; and
the Santa Fe Group.
31
Questions
Corresponding Author:
Ira B. Lamster D.D.S., M.M.Sc. Clinical Professor
Stony Brook University School of Dental Medicine Dean Emeritus
Columbia University College of Dental Medicine
Email: [email protected]